In the early 2000s I saw an episode of The Oprah Winfrey Show that left a permanent impression on me. Oprah hosted Dr. Catherine Hamlin, a Nobel Peace Prize nominee who opened the Addis Ababa Fistula Hospital in Ethiopia.
[Dr. Catherine Hamlin; photo courtesy of Oprah Winfrey website]
WHAT IS OBSTETRIC FISTULA?
A medical fistula is a hole in living tissue. An obstetric fistula is a hole that develops in the tissue separating the vagina (birth canal) from the bladder and/or large intestine during labor.
Fistula most often occurs with very young mothers because their bodies are small and not fully developed, and access to surgical delivery such as a caesarean section has not been available, or precluded by the patient’s poverty. Long labor, young mother, and size of baby all increase risk of fistula.
[Areas where fistula usually occur; photo courtesy of Wikipedia]
The root causes of fistula, according to the Fistula Foundation, are poverty and the low status of women and girls. Poverty leads to malnutrition, which leads to stunted growth and an underdeveloped skeleton and pelvis. Obstructed, lengthy labor is a known cause of fistula.
Fistula used to be common in the US and Europe as well, but its frequency decreased greatly in the late 19th and early 20th century due to improved obstetric care, nutrition, and the use of C-sections to relieve obstructed labor.
CONSEQUENCES OF FISTULA
Left untreated, the fistula causes a constant stream of urine and sometimes feces to drip, leaving a trail and odor wherever these young mothers go. The vaginal opening does not have a sphincter muscle and is thus unable to retain body waste, resulting in the constant leak.
In Ethiopia, thousands of young girls suffer from this condition, largely due to early marriage and childbirth. Obstetric fistula does not heal without medical intervention.
The result is the young woman being socially ostracized. She is often separated from her family’s living quarters and shamed into living alone. She is unable to access public transportation or enter public areas due to the odor and lack of hygiene.
Lack of family and societal support often results in depression, leading to further lack of hygiene and inability to obtain adequate nutrition, thus complicating the situation.
The Fistula Foundation estimates that there are currently over one million women still suffering from obstetric fistula worldwide, mostly in sub-Saharan Africa and Asia.
In developing countries, fewer than 6 in 10 women give birth with a trained professional, such as a midwife or doctor, present. Complications arise in about 15% of all births, and with no one present to treat the women, injuries like fistula occur, and in the worst cases, maternal and infant death.
Fistula is easily preventable with education and proper obstetric care. Once a fistula develops, however, only surgery can treat it. The surgery is generally very simple and the success rate is about 95%; however before it can occur the patients may need to be treated for the common conditions of anemia, malnutrition, and malaria.
[Addis Ababa Fistula Hospital, photo courtesy of Wikipedia]
The cost of the surgery varies from $100-$400 USD, including the surgical procedure, postop care, and rehab. Successful surgery enables women to resume completely normal lives and have more children, although C-sections are usually recommended to prevent recurring fistulas, depending on how soon pregnancy recurs.
CHALLENGES IN FISTULA TREATMENT
The main challenge is the very high number of women needing this surgery; helping them with access to facilities (some walk for days to reach the nearest hospital providing the surgery); and the cost of treatment. Several hundred USD is an impossible price for many patients and they can’t afford the surgery.
[Dara Konso, Ethiopia, by Ted Chang]
Regional availability of hospitals varies; in Benin only one expatriate doctor was available for a few months a year as of this writing. In Niger, only two medical facilities treat fistula patients. Estimates are that it would take up to 75,000 new emergency obstetric facilities in Africa alone to prevent any more fistula cases from occurring.
[Addis Ababa, Harar Old Town, by Ted Chang]
Education is another significant challenge. Many women are not aware that treatment is available, or what the cause is. Because fistula is a condition of shame and embarrassment, most women hide themselves and suffer in silence. Post-operative education is also essential in preventing recurrence.
IF YOU WISH TO HELP
Hamlin Fistula USA accepts donations and has an employer matching program. Money goes to help patients pay for surgery and to educate midwives to go out into the population and provide obstetric care.
Other resources include: